2. Date of Vacation
4. Date of Departure*
5. Date of Return*
7. Your Contact Info
9. First Name*
10. Last Name*
12. Address1*
14. Address2
16. City*
17. State*
18. Zip*
20. Primary Phone*

    Not the landline to your residence we are checking

21. Secondary Phone

    Not the landline to your residence we are checking

    
    

23. Email*
24. Secondary Email
28. Trusted Person Contact Information

    Someone we can contact, preferably locally, about your residence, while you are gone, if needed. 

    Preferably not someone traveling with your vacation party.

30. First Name*
31. Last Name*
33. Address1
35. Address2
37. City
38. State
39. Zip
41. Primary Phone*
42. Secondary Phone
44. Do They Have a Key to your Residence?*
    -- Select One --YesNo
48. Secondary Trusted Person Contact Information

    Someone we can contact, preferably locally, about your residence, while you are gone, if needed. 

    Preferably not someone traveling with your vacation party.

    
    

50. First Name
51. Last Name
53. Address1
55. Address2
57. City
58. State
59. Zip
61. Primary Phone
62. Secondary Phone
64. Do they have a key to your residence?
    -- Select One --YesNo
68. Phone number you can be reached at while out of town*
70. Vacation address (optional)
74. Premise Information
76. Will any lights be left on in your residence?*

    1. Yes
    2. No
77. Will any lights left on be on a timer?

    1. Yes
    2. No
    3. Not Applicable (no lights left on)
79. Will there be a radio or audible sound source left on while you are gone?*

    1. Yes
    2. No
80. Will the radio or audible sound source left on be on a timer?*

    1. Yes
    2. No
    3. Not Applicable (No sound source left on while gone)
82. Is there an alarm system on the premise?*

    1. Yes
    2. No
84. Alarm Company
86. Are you leaving any vehicles on your premise?*

    (Do not include those parked in closed garages)

    1. Yes
    2. No
88. Vehicle 1 Make / Model / Color

    Example: Ford Explorer Silver

89. Vehicle 1 Location
91. Vehicle 2 Make / Model / Color
92. Vehicle 2 Location
94. Have you stopped your mail and/or newspaper delivery*

    1. Yes
    2. No
95. Do you have any deliveries scheduled while you are gone?*

    1. Yes
    2. No

    Example: Amazon deliveries

97. Will there be anyone else in the home or property?*

    (for example a neighbor, family member, landscaper, contractors, someone to water plants, etc.)

    1. Yes (please provide details in notes below including dates, times, vehicles, names, and where they should be (inside/outside) if possible) (providing this information will greatly assist Officers)
    2. No
101. Additional Information
103. Please provide any additional information that you would like the Police Department to know regarding your home.*

     Please type none if there is no additional information Officers should know when checking your home

105. By completing this form, you grant the Creve Coeur Police Department permission to enter your home or premises upon exigent circumstances, emergencies, signs of a break in or an unsecured door/window during the period of your requested vacation check.*

     1. I have read and agree to the above statement
107. For questions or issues completing this form please contact the Crime Prevention Office at (314) 442-2075 or email crimeprevention@crevecoeurmo.gov
109. For more information, contact the Crime Prevention Office at (314) 442-2075.
Leave This Blank:


111. 1. Receive an email copy of this form.
112. Email address

     This field is not part of the form submission.

113. Submit

* indicates a required field